A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Respiratory rate 16/min

Blood pressure 110/70 mm Hg

400 mL of drainage in the collection chamber within 4 hr

Fluctuation in the water seal chamber with respiration

Answer and Explanation

The Correct Answer is C

A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.

B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.

C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.

D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.

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Correct Answer is A

Explanation

A. “I will consider what is going to benefit the most people when making decisions.”: This is correct. Utilitarianism is an ethical theory that focuses on the greatest good for the greatest number of people. Decisions are made based on the outcomes that benefit the most individuals, even if they might not always align with individual preferences.

B. "I will respect the decision of a client who has a chronic illness to stop treatment.": This reflects the principle of autonomy, not utilitarianism. Autonomy focuses on respecting an individual's right to make their own decisions, rather than the greater good.

C. "I will place a higher emphasis on human dignity than on the needs of a group.": This statement leans more toward a deontological perspective, which prioritizes individual rights and dignity over collective benefits.

D. "I will withhold a terminal diagnosis from a client who has cancer.": This reflects a paternalistic approach, where decisions are made by healthcare providers for the patient, which is not a principle of utilitarianism. Utilitarianism would consider the benefits and harms of full disclosure to the patient, rather than withholding information.

A. Turn on overhead lights briefly when checking IV lines. B. Open curtains between clients in semiprivate rooms. C. Wear shoes with rubber soles. D. Conduct change-of-shift report near the clients' rooms.

Correct Answer is C

Explanation

A. Turning on overhead lights briefly when checking IV lines is incorrect. Bright lights can disrupt sleep cycles, especially for clients who are light-sensitive or have fragmented sleep patterns. Instead, using a flashlight or bedside lamp is recommended to minimize disturbances.

B. Opening curtains between clients in semiprivate rooms is incorrect. Keeping curtains closed provides privacy and helps block light and noise, both of which can interfere with restful sleep.

C. Wearing shoes with rubber soles is correct. Rubber-soled shoes reduce noise from footsteps, minimizing disturbances in client rooms and creating a quieter environment that promotes sleep.

D. Conducting change-of-shift report near the clients' rooms is incorrect. Shift reports should be conducted away from patient areas to prevent unnecessary noise and disruption during sleep hours.

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A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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